Latino/a Leadership Opportunity Program Application
1995-1996
Carefully follow the instructions outlined in the accompanying brochure.
Name: _______________________________________________________________________
Present address: _______________________________________________________________
Permanent Address: ____________________________________________________________
Telephone (temporary and permanent): _____________________________________________
Student ID#_______________________________Major_______________________________
GPA__________
Institution Presently Attending ______________Year in School_________________________
Completion Date ______________________
Date of Birth _______________Place of Birth________________
Gender: F__________M___________
Ethnicity: Chicano/Mexicano-American ___________ Cuban -American __________
Puerto-Rican Central-American, specify ________________
South-American, specify ___________________ Caribbean, specify________________
Bilingual (Spanish/English)? ___________________
List community, university organizations or activities important to you.
List scholastic or academic honors including scholarships, fellowships, prizes, honor societies, etc.
Parental Occupation
Father ________________________Mother ______________________________
Parental Level of Education
Father:
Less than HS ______HS ______Some College ___________College (list Degree) Prof. Training _________
Mother:
Less than HS ______HS ______Some College ______________College (list Degree) ____________Prof. Training __________________ Annual Family House Income (optional) $ _________________
| Names of the two people submitting recommendations for you. | Is this letter enclosed with this form? | If not, date you gave the form to the recommender |
| 1________________________ | ___Yes ___No | ______________ |
| 2. _______________________ | ___Yes ___No | ______________ |
Attached Personal Statement_____ Copy of current transcripts ______________
The information I have provided on this application form and in any related material is complete and accurate.
Signiture: _______________________________________________ Date: ______________
APPLICATION DEADLINE: